Conditions of Confinement in U.S. Carceral Facilities During COVID-19: Individuals Speak—Incarcerated During the COVID-19 Epidemic

Objectives: We aimed to describe conditions of confinement among people incarcerated in the United States during the coronavirus disease 2019 (COVID-19) pandemic using a community-science data collection approach. Methods: We developed a web-based survey with community partners to collect information on confinement conditions (COVID-19 safety, basic needs, support). Formerly incarcerated adults released after March 1, 2020, or nonincarcerated adults in communication with an incarcerated person (proxy) were recruited through social media from July 25, 2020 to March 27, 2021. Descriptive statistics were estimated in aggregate and separately by proxy or formerly incarcerated status. Responses between proxy and formerly incarcerated respondents were compared using Chi-square or Fisher's exact tests based on α=0.05. Results: Of 378 responses, 94% were by proxy, and 76% reflected state prison conditions. Participants reported inability to physically distance (≥6 ft at all times; 92%), inadequate access to soap (89%), water (46%), toilet paper (49%), and showers (68%) for incarcerated people. Among those receiving prepandemic mental health care, 75% reported reduced care for incarcerated people. Responses were consistent between formerly incarcerated and proxy respondents, although responses by formerly incarcerated people were limited. Conclusions: Our findings suggest that a web-based community-science data collection approach through nonincarcerated community members is feasible; however, recruitment of recently released individuals may require additional resources. Our data obtained primarily through individuals in communication with an incarcerated person suggest COVID-19 safety and basic needs were not sufficiently addressed within some carceral settings in 2020–2021. The perspectives of incarcerated individuals should be leveraged in assessing crisis–response strategies.

Additionally, prevalent chronic conditions (i.e., diabetes, hypertension, and asthma) place incarcerated populations at greater risk of COVID-19-related morbidity and mortality. 13 Despite the waning of the pandemic in the general population, conditions of confinement experienced by incarcerated populations can provide important insight toward planning humane responses to inevitable future infectious disease transmission.
While physical distancing, mask wearing, handwashing, and testing were recommended mitigation strategies by the Centers of Disease Control and Prevention (CDC) for carceral facilities, 14 data indicate that mitigation strategies reported by state-level DOCs were irregularly implemented and punitive. 15,16 Additionally, incarcerated individuals have reported inadequate access to soap, water, and disinfectant supplies, 17 and extensive periods of lockdowns (suspension of activities and confinement restricted to housing areas) or solitary confinement (housing with minimal to rare contact with others) to achieve physical distancing. [17][18][19] While anecdotal evidence is compelling, robust quantitative data from the perspectives of incarcerated people during the pandemic are limited, [20][21][22] of which only two were from the United States. 21,22 Yet, access to basic needs, medical care, and lockdown procedures were not examined. The unique perspective of directly impacted people, which has historically been ignored, is essential to the evaluation of emergent crisis response within carceral facilities. While community advocates identified the need for timely and wide-spread data on confinement conditions, obtaining research agreements from all U.S. carceral systems to directly survey currently incarcerated people was deemed a barrier to these urgent data needs during a rapidly changing public health emergency.
Therefore, we partnered with community advocates to design and disseminate a web-based survey to collect detailed data on conditions of confinement and examine the feasibility of collecting data through outreach to community members such as loved ones, professional partners, and recently released individuals. Our methodological approach demonstrates how community members can contribute to epidemiological data collection efforts, the identification of salient health outcomes, and potential discordance between policy and implementation.

Instrument development
In May 2020, a Community Advisory Board (CAB) was convened to examine conditions experienced by individuals incarcerated during the pandemic. The CAB included formerly incarcerated advocates from local and national organizations, Families for Justice as Healing, Justice 4 Housing, the National Council of Incarcerated and Formerly Incarcerated Women and Girls, and the Partakers Organization. Each CAB member requested the inclusion of statements of commitment to their community and organizational mission (Supplementary Data S1). At study onset, there were no validated instruments to examine confinement conditions among incarcerated individuals during the pandemic; therefore, we developed a survey of COVID-19 safety, basic needs, support, and demographic factors. Questions were developed based on carceral system mitigation strategies, CDC guidelines, 14 community-informed concerns, 23 anecdotal evidence, and surveys targeting the general population.
The instrument was piloted among 12 individuals who had been incarcerated and released after March 1, 2020 or were in communication with an incarcerated individual. The survey included questions regarding completion time, accessibility, and appropriateness of survey content. In partnership, we reviewed the pilot findings, implemented changes, and planned survey dissemination.
The final instrument consisted of 42 questions, (37 multiple choice, 5 open-response; Supplementary Data S2), of which three were administered only to proxies and seven only to formerly incarcerated respondents (FIR). Survey data were collected anonymously using Research Electronic Data Capture and distributed using a snowball sampling method through Twitter, Facebook, and by e-mail to community partner organizations, medical and legal professionals, and local politicians. Proxy respondents were allowed to indicate whether they were an individual responding on the behalf of an incarcerated loved one, or a medical or legal professional.

Study sample
The final study sample comprised 378 adults ( ‡ 18 years) who met the following criteria: (1) formerly incarcerated individual released after March 1, 2020 (beginning of the U.S. pandemic response; n = 21), or (2) had been in contact with someone currently incarcerated (proxy; n = 357). To maximize reported data, questions could be skipped. Proxies in contact with multiple incarcerated individuals were asked to submit a separate survey for each person, unless proxies were legal/medical professionals, who were prompted to report the number of people for whom the information was applicable.

Statistical analyses
All primary analyses were descriptive and thus did not include statistical hypothesis testing. Frequencies and relative frequencies were calculated for each question based on available data for all respondents in aggregate, with a missing indicator for skipped questions. Geographic regions were defined according to U.S. Census Bureau classifications. 24 Illustrative qualitative data were selected to provide context to quantitative findings.
Results were reported in aggregate and stratified by participant type (proxy/FIR). We assessed feasibility by examining internal validity, completed question-naires, sample size, and missingness. The distribution of responses (excluding missing values) by proxies compared with FIRs for questions regarding COVID-19 safety, basic needs, and support were compared to assess internal validity. Individual results for FIRs should be carefully considered as the sample size is small.
Comparisons were conducted using two-sided Fisher's exact tests based on an a = 0.05. We also conducted sensitivity analyses to examine differences over time and geography for variables with inconsistencies between proxies and FIRs. All analyses were conducted using Stata/IC (version 16.1; College Station, TX).

Statement of ethics
This study was approved by the Institutional Review Board of the Mass General Brigham and deemed exempt because no personal identifiers were collected and the research posed minimal risk. All procedures were in accordance with institutional guidelines. However, we acknowledge that these data represent individuals who have been incarcerated and those who know them personally.

COVID-19 safety
Responses about COVID-19 safety measures and access to basic needs are reported in aggregate and by respondent role ( Table 2). Most participants reported exposure to lockdown procedures by incarcerated people (proxy = 89.9%, FIR = 79.0%). A length of confinement > 20 h/day was reported by 86% of proxies and 93% of FIRs, with 50% of proxies and 33% of FIRs reporting a duration of > 3 months. Over 90% of total respondents indicated an inability of incarcerated people to maintain the CDC-recommended six-foot distance from others, and nearly 30% of both groups reported individuals were housed with ‡ 2 people. Reports of PPE provision for incarcerated people (primarily face masks) were higher among proxies (83%) than FIRs (61%), whereas 85% and 79%, respectively, reported inconsistent staff use of PPE.
Furthermore, over one-third of respondents overall reported that individuals who experienced COVID-19 symptoms were returned to their cells, irrespective of their cellmate's symptoms (proxy = 35%, FIR = 55%).
Additionally, participants reported that individuals were unable to take their belongings if moved due to COVID-19 (proxy = 5%, FIR = 73%). One proxy respondent shared, My husband caught covid because he was transferred from firecamp back to prison. Officially there were no transfers allowed during this time. He then got infected back at the main prison, got thrown into the SHU [Special Housing Unit]. He had none of his property, absolutely nothing for 2 weeks.
Medical care and support resources were also affected by the pandemic response (Table 2). A delay beyond normal delivery of medical care for flu-like symptoms was reported by > 80% of respondents overall (proxy = 81%, FIR = 82%). One proxy respondent reported, My loved one recently got infected with COVID-19 and is also suffering for underlying medical conditions (chronic Hepatitis B and asthma). He didn't receive any medical treatments other than having his inhaler with him. The only ''treatment'' that was given to some individuals were over-the-counter medications such as Tylenol to reduce some flu-like symptoms. My loved one is still suffering from some lingering symptoms such as wheezing and coughing.
Similarly, of those receiving mental health care before the pandemic, 96% of proxies and 89% of FIRs reported less or no care received. Access to legal services were also reportedly reduced (proxy = 81%, FIR = 57%) and parole hearings delayed ( > 30% in both groups).

Questions only answered by FIR
Questions about PPE replacement, increased stress, and receipt of financial support were asked only to FIRs (n = 21; Table 3). Eighty-two percent indicated new PPE was provided less than once per week.  Another FIR shared, Being locked in a cell for 23 hours and 40 minutes a day for weeks at a time (whenever there was a report of a positive case among staff/incarcerated citizens was extremely stressful). I often considered hurting other prisoners or the guards simply because I was angry. I am not a violent person.

Questions only answered by proxy respondents
Questions about recency of communication, COVID-19 concerns, and support of incarcerated individuals were specifically asked of proxies. Most had communicated with the individual within the past week (85%) and reported increased expenses to support the individual (82%). One proxy respondent shared, There is a food shortage and many are not opting for mess hall. I am supporting 10 women & it's difficult and expensive.
A high proportion (70%) reported concerns about contracting the virus upon visitation reinstatement or from the incarcerated individual if released (50%).

Pilot feasibility
Overall, 23 surveys were initiated but not completed; however, response rates could not be calculated due to survey link distribution through social media and partner networks. Missingness was examined qualitatively to assess which variables were least likely to be answered by proxies or FIRs (Supplementary Data S3). Overall missing data for individual questions, which ranged from 5% for facility lockdown to 63% for changes to parole hearing, were higher for proxies than FIRs.
The distribution of responses between proxies and FIRs were compared for key metrics and were found to be consistent ( p > 0.05) for all but two questions (Table 4). Proxies were significantly more likely to report a facility being on lockdown (94%) than FIRs (79%, p = 0.03) and fewer proxies (30%) reported that incarcerated individuals had access to daily showers compared with 63% of FIRs ( p = 0.01). However, cautious interpretation is warranted due to the sample size limitations.

Discussion
To our knowledge, this is the first study designed and distributed in partnership with formerly incarcerated individuals to collect data on confinement conditions among individuals incarcerated across multiple states and systems. Our community-science data collection methods facilitated data transparency in a timeconstrained setting by leveraging the strength of community ties. Our findings, primarily by proxy reports, suggest that in at least some facilities, individuals reported being unable to maintain physical distance, despite extensive lockdown periods, and lacked access to basic needs (i.e., soap, water, toilet paper, and showers). Respondents also indicated that incarcerated people had limited access to health care and legal aid. Lastly, the feasibility of this method was demonstrated by the ample sample size, and the comparability of findings to other sources of data (i.e., academic and popular press); however, resources would be needed to further engage formerly incarcerated individuals. Understanding conditions of confinement during the COVID-19 pandemic from the perspective of incarcerated individuals is critical for crisis response planning and surveillance of standard operating procedures since public-facing policies may not align with actual implementation. Yet, incarcerated people have limited opportunities to challenge deviations from protocol. 25,26 Moreover, carceral systems are generally not mandated to publicly share data on the health of incarcerated people, impairing external oversight. 27 Unsurprisingly, there are limited data examining the experiences of the incarcerated during the pandemic. [20][21][22] Among the few studies available, [20][21][22] only two addressed confinement conditions in the United States. 21,22 Between April and November 2020, the COVID-19 Questionnaire for Correctional Populations (CQCP) survey was administered to 327 individuals incarcerated in three U.S. states to collect data on mitigation strategies among staff and incarcerated individuals. 22 Our findings were similar to the CQCP study for  some conditions, such as soap provision (67.9% vs. CQCP = 70.6%) but differed for physical distancing (7.9% vs. CQCP = 66.4%). This may be due to wording differences, such as the CQCP asking participants about the ability to maintain physical distancing ''if possible'' rather than ''at all times.'' Our study expands our understanding by increasing geographic variability, reflecting a longer time period ( July 2020-March 2021 vs. April 2020-November 2020), and by including questions on lockdown, basic needs, and mental health care access.
Furthermore, a mixed methods study was conducted to understand the perceived risk of COVID-19 among 41 incarcerated males experiencing ‡ 20 h/day of solitary confinement. 21 In contrast to our findings, participants reported they felt more protected from COVID-19 than the general incarcerated population because of the solitary confinement measures they were subjected to, but reported infection was inevitable due to staff interactions and unsanitary food distribution. However, due to the small and highly selected sample, comparability of findings may be limited.
Our findings also paralleled data published by the popular media. The Essie Justice Group conducted a survey of 729 people in contact with an incarcerated individual. Sixty-two percent reported the incarcerated individual feared losing their lives, 28 similar to 88% of FIRs in this study who worried about getting COVID-19 ''most of the time.'' Similarly, a survey among 50 individuals formerly detained by ICE reported that 80% were not able to maintain physical distance while eating, consistent with the 92% in our study who reported an inability to maintain physical distance. 17 Discrepancies between CDC recommended mitigation strategies and data reported in this study (Fig. 1 of systems reported giving PPE to incarcerated individuals, while others disallowed it or failed to mandate its use, aligning with the low proportion of staff PPE use identified in our study. However, the timing of policy implementation was not reported and data for jails and detention centers are not unavailable. 16 Furthermore, some mitigation strategies may lead to physical and psychological distress. Restrictive housing has been associated with psychological harm, [29][30][31] including anxiety, depression, aggression, self-harm, and increased mortality postrelease, 29,32 although it should be noted that empirical data are sparse and differences in study outcomes and design features limit consistency and generalizability of findings. 33 Despite recommendations against long-term restrictive housing ( > 15 days) by the United Nations, 34 U.S. Department of Justice, 35 National Commission on Correctional Health Care, 36 lockdowns have been a prioritized mitigation approach; however, the long-term consequences of its use during the pandemic and delays in medical and mental health care are uncertain.
Several limitations of this study should be considered. Generalizability of our findings may be limited and biased toward those with internet access and social media users. Responses were not uniformly geographically distributed due to the nature of our community partner networks; thus, results were not stratified by geographic location due to sample size considerations. Generalizability of our sample by race and ethnicity is also uncertain due to missing data for these variables. Although our sample may overrepresent conditions in female facilities given our partner networks, there is no evidence to suggest that conditions would be improved for incarcerated males or individuals of color. Furthermore, individual results for FIRs should be considered carefully given the small sample size. Despite these limitations, general comparisons with other studies support the observed patterns.
Additionally, data from proxies may not be robust for all variables indicated by high proportions of missing data for some questions, such as parole hearings. For example, when comparing proxy to FIR responses, significantly more FIRs reported ability to shower daily if wanted, while more proxies reported lockdown conditions. However, 16% of FIRs who answered the questions regarding showering and lockdown were released before May 2020, before widespread response in all states, and were incarcerated in Florida, potentially reflecting variability in state responses. Although sensitivity analysis suggested high internal validity for other variables, these data should be interpreted cautiously due to sample size constraints.
Finally, although we collected data on the date of release, we did not collect the duration of incarceration. Our data reflect protocols implemented within the 1st year of the pandemic; however, policies varied substantially across and within systems, were implemented at different periods of time during the pandemic and recommendations for mitigation shifted. 15,29 Thus, we could not assess the length of exposure to long-term lockdown or other COVID-19 mitigation strategies and findings may not reflect current conditions. Although we did not specifically exclude correctional staff, this group was not specifically engaged given recruitment through our community partner networks; however, their perspective is valuable and should be considered in future work.

Health Equity Implications
Our data demonstrate that some incarcerated people reported experiencing inadequate implementation of safety protocols, difficulty accessing basic needs, and were subjected to long periods of restricted confinement. Further work is needed to confirm these findings in a representative sample. Our methods demonstrate the power of grassroots action to design a culturally relevant instrument and research study to collect descriptive, surveillance data of urgent community-identified needs. Data collected through these approaches can aid in addressing concerns of data transparency and oversight, and further support humane policy implementation, such as the use of decarceration, diversion programs, and compassionate release. Therefore, we urge public health leaders to engage with community organizations to develop meaningful research questions, leverage community strengths, and shape policy.